1275768087 NPI number — DR. RANA ABDUL-KHALEK MD

Table of content: DR. DEJEUNEE DARENSBURG RPH (NPI 1871861906)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275768087 NPI number — DR. RANA ABDUL-KHALEK MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ABDUL-KHALEK
Provider First Name:
RANA
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1275768087
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39 KENT RD
Provider Second Line Business Mailing Address:
SUITE 1
Provider Business Mailing Address City Name:
TIFTON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31794-1698
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
229-391-4130
Provider Business Mailing Address Fax Number:
229-391-4138

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5000 PRAIRIE ROSE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSCOE
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
61073-7792
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-971-2000
Provider Business Practice Location Address Fax Number:
815-971-9070
Provider Enumeration Date:
05/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  072447 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 036125328 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1275768087 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 036125328 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 10193 . This is a "MERCY CARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1275768087 . This is a "BLUE CROSS BLUE SHIELD" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1275768087 . This is a "MOLINA" identifier . This identifiers is of the category "OTHER".




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